Malignant pain

Neuropathic pain maybe considered to be a type of chronic non-malignant pain involving disease of the central and peripheral... 

The role of NSAIDs and opioids in chronic non-malignant pain has been discussed however, a review of adjuvant agents... 

Potent opioids act through opioid receptors in the central nervous system where they inhibit the transport of pain impulses. They are mostly used for treatment of malignant cancer pain and for post-operative pain. Severe, long-term non-malignant pain, e.g. in ischaemic leg ulcers, sometimes necessitates the use of opioids. The risk of treatment discontinuation due to adverse reactions is high. 

Clonidine has been launched for the treatment of cancer pain (Boehringer Ingelheim). It is effective against malignant and non-malignant pain after spinal administration (Glynn et al., 1988 Eisenach et al., 1995). 

Onghena, P. and van Houdenhove, B. Antidepressant-induced analgesia in chronic non-malignant pain a meta-analysis of 39 placebo-controlled studies, Pain 1992,49, 205-219. 

Skaer, T.L., Practice guidelines for transdermal opioids in malignant pain, Drugs, 64(23), 2629-38, 2004. 

Rhodin, A., Gronbladh, L., Nilsson, L. H., and Gordh, T. (2006). Methadone treatment of chronic non-malignant pain and opioid dependence-a long-term follow-up. Eur.J. Pain 10, 271-278. 

In a prospective uncontrolled study of intrathecal methadone in 24 patients with a history of intractable chronic non-malignant pain, methadone was a better analgesic than morphine, with improved quality of life and no adverse effects in 13 patients (6). The final rates of methadone infusion were 20% higher than the preceding morphine rates. 

Libretto SE. Use of transdermal fentanyl in patients with continuous non-malignant pain a case report series. Clin Drug Invest 2002 22 473-83. 

In a retrospective review of 37 patients with chronic non-malignant pain (mostly from failed lumbosacral spine surgery) treated with intrathecal hydromorphone there was an analgesic response in six of the 16 patients who were switched from morphine to hydromorphone because of poor pain relief (1). Opioid-related adverse effects, such as nausea, vomiting, pruritus, and sedation, were also reduced by hydromorphone in the 21 patients who were switched to hydromorphone because of morphine-related adverse effects, especially 1 month after use. These results should be treated cautiously, because of the limitations of a retrospective study that lacks strict inclusion criteria, with obvious population bias and under-reporting, and without standardized procedures for rotation to hydromorphone. 

The use of intrathecal hydromorphone in the management of chronic non-malignant pain has been described... 

The use of modified-release tramadol in chronic malignant pain has been examined in an open, prospective study in 146 patients with moderate to severe cancer pain 90 patients completed the 6-week trial (53). Dropouts were due to opioid adverse effects (20%), inadequate pain relief (9%), or both (2.5%). There was at least one adverse effect in 86%. Overall, 433 adverse effect events were reported but some reduced in frequency over the 6 weeks. Modified-release tramadol (400 mg/day) provided fast and efficient pain relief in almost 60% of patients both during initial dosing and long-term treatment. 

Petzke F, Radbruch L, Sabatowski R, Karthaus M, Mertens A. Slow-release tramadol for treatment of chronic malignant pain—an open multicenter trial. Support Care Cancer 2001 9(l) 48-54. 

Optimal prescribing for chronic non-malignant pain is at times achieved through the use of short-acting opioids as rescue medication. The effect of rescue opioids on the incidence of adverse reactions has been reviewed [6 ]. There was no evidence for an increase or decrease in the incidence of common adverse events when rescue opioids were administered. 

Psychological The effects of intrathecal infusion of morphine at a mean rate of 0.23 mg/day on pain perception and psychosocial function have been investigated prospectively in 30 patients with chronic non-malignant pain who failed to respond to multimodal analgesics [41 ]. Over 24 months, 26 of them improved their daily functionality, 12 returned to full-time employment, and 8 retired individuals no longer required live-in assistance. 

Devulder J, Jacobs A, Richarz U, Wiggett H. Impact of opioid rescue medication for breakthrough pain on the efficacy and tolerability of long-acting opioids in patients with chronic non-malignant pain. Br J Anaesth 2009 103(4) 576-85. 

Fredheim OM, Skurtveit S, Moroz A, Breivik H, BorchgrevinkPC (2009) Prescription pattern of codeine for non-malignant pain a pharmacoepidemiological study from the Norwegian prescription database. Acta Anaesthesiol Scand 53(5) 627-633... 

Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain program for chronic non-malignant pain. / Pain 2006 7 779-793. 

Chronic non-malignancy pain morphine can be used for moderate to severe chronic pain especially in terminally ill patients. 

Chronic non-malignancy pain controlled-release oral formulation of morphine sulfate could be administered in a more convenient schedule than immediate-release oral morphine products, and significantly improves pain control at a lower daily opioid dose, with less rescue doses for breakthrough pain. 

Studies on treatment of chronic non-malignancy pain, such ash chronic low back pain, showed a measmable improvement in symptoms when patients took opioid plus NSAID combination drugs versus the drugs alone. As with cancer pain, the duration of treatment in the studies was short (8 days). It is reasonable to suspect that longer duration of therapy would be necessary in these patients. Therefore, further studies are needed to determine the safety and efficacy of longer duration therapies in this patient population. 

As an analgesic agent, hydrocodone bitartrate is used for the symptomatic relief of temporary pain that is moderate to moderately severe, such as acute postoperative pain. It may also be appropriate for the symptomatic treatment of pain associated with acute medical disorders, particularly in the treatment of migraine headaches. For the treatment of chronic non-malignant pain, hydrocodone bitartrate preparations should only be used when non-opioid pharmacological and non-pharmacological modalities have been exhausted and fail to provide measurable symptomatic relief. In the management of severe chronic pain associated with cancer or other terminal illness, hydrocodone... 

Relief of moderate to severe acute pain, surgical pain, medical pain, chronic non-malignancy pain, cancer pain and labor pain. 

In addition to maintenance treatment for opioid-dependent individuals, methadone is very useful as a long-acting analgesic, particularly for neuropathic pain syndromes that accompany malignancy, and chronic non-malignancy pain, or where the efficacy and side effects of commonly employed opioids are unacceptable. Pain which is poorly responsive to morphine or other opioid agonists should be identified quickly so that futile dose escalation and intolerability can be avoided. 

Tramadol ER was administered to a total of 3108 patients during studies conducted in the USA. These included four double-blind studies in patients with osteoarthritis and/or chronic low back pain and one open-label study in patients with chronic non-malig-nant pain. A total of 901 patients were 65 years or older. Adverse events increased with dose from 100 mg to 400 mg in the two pooled, 12-week, randomized, double-blind, placebo-controlled studies in patients with chronic non-malignant pain [4) (see Table 30.1)... 

Moore RA, McQuay HJ. Prevalence of opioid adverse events in chronic non-malignant pain systematic review of randomised trials of oral opioids. Arthritis Res aer2005 7 R1046-1051. 

Chronic non-malignancy pain ibuprofen frequently is used to assist in the management of various chronic pain syndromes such as osteoarthritis, rheumatoid arthritis, low back pain, fibromyalgia, and peripheral neuropathy. 

Chronic non-malignancy pain as an anesthetic and analgesic option when patients present with medical pain or for acute surgical pain needs. 

Chronic non-malignancy pain oral or transdermal clonidine is less commonly used in the chronic setting for pain control due to the increased level of sedation. However, it may be helpful in managing patients who have been on high-dose narcotics as it has some efficacy in withdrawal syndromes. It can also be used for migraines. 

Chronic non-malignancy pain antihistamines may be helpful in patients with myofascial pain, as one... 

A search of completed studies also reveals the following effectiveness and tolerability of OROS Hydromorphone and Hydromorphone IR in chronic pain, safety and tolerahihty of OROS Hydromorphone in long-term use for cancer pain, effectiveness versus placebo for chronic low hack pain, in chronic non-malignant pain, safety and impact on quahty of life, randomized open-label for safety and effectiveness in short-term use for post-operative pain, dose proportionality studies, OROS Hydromorphone versus morphine in cancer patients, and safety and effectiveness in patients with osteoarthritis. 

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